Making Good on Disease Intelligence
By Vidal Seegobin:
The attempted Christmas Day bombing of a Northwest flight from Amsterdam to Detroit once again thrust airport security into the headlines. It ignited a flurry of investigations into how 23-year-old Abdul Mutallab managed to board an international flight despite several "red flags" and why the intelligence community failed to "connect the dots." And the incident struck a chord of fear among the flying public.
Contrast this with the lack of public outcry when officials disclosed, only a few weeks later, that a patient with communicable tuberculosis boarded a transcontinental flight from Philadelphia to San Francisco on January 9, 2010. TSA officials stopped the individual before he could board the international leg of his journey, preventing further exposures. But the infected passenger was on the public health "Do Not Board" list and should have been prevented from boarding any flight by airline agents.
The patient was diagnosed with TB the day before his flight in Philadelphia. His doctor, fearing that the patient would fly, reported his name to CDC, which placed his name on the Do Not Board list. TSA reports transmitting the updated list to US Airways the next day, but he still received a boarding pass. The Do Not Board protocol requires the airlines to prevent listed patients from boarding. US Airways has, so far, promised to investigate in conjunction with TSA and CDC.
Tuberculosis is the most prominent of the diseases CDC currently encounters with respect to public health and airlines. TB, which was declared a global public health emergency in 1993, assaults the human respiratory system and infects approximately 9 million new patients every year. While TB is not the most dangerous security threat faced by the US or the world, cases of multi-drug resistant TB-which are difficult to treat and a growing public health concern-are on the rise. Standard cases are treatable and generally will not be flagged for the Do Not Board list - unless the infected individual demonstrates a blatant disregard for the public's health. Multi-drug resistant cases trigger a more rigorous review and are more likely to make the list. But, again, the person must first demonstrate a lack of regard for public health. CDC recommends that individuals with infectious TB avoid the unnecessary risk of spreading the disease in the enclosed space of an airplane.
The legal and procedural challenges to protecting the public from TB-infected passengers leaving the country came to light in March 2007. Andrew Speaker, an Atlanta lawyer with multi-drug resistant TB, led CDC officials on a merry trans-Atlantic chase. A U.S. Customs and Border Protection officer then apparently ignored a notice to prevent Mr. Speaker from freely re-entering the country. The case was splashed across headlines and instigated congressional scrutiny on the shortcomings in health-related security processes at airports and borders.
Within weeks, CDC and DHS established the public health "Do Not Board" list as a tool to protect the public from infectious disease threats on airlines. Health officials contact CDC when they believe that an individual with a highly contagious disease poses a risk to the flying public. CDC evaluates each case and compiles the "Do Not Board" list with the Department of Homeland Security (DHS.) DHS, through TSA, then supplies the list to air carriers.
The list is mostly designed to protect the flying public against an increasing threat of multi-drug resistant TB. To be added to the list, individuals must be judged not only highly contagious but likely to defy all legal and medical advice against boarding commercial flights. CDC and DHS received only 42 names in the program's first full year and added just 33 to the list. (All had infectious TB; at least two tried to defy air travel restrictions.) Because individuals cycle off the list following successful treatment, the list involves handfuls, not hundreds, of names at any given time. The list represents the best efforts of CDC and DHS to identity health threats to other flyers systematically, within legal frameworks for isolation and quarantine, and with sensitivity to individual rights.
The public health "Do Not Board" list should provide a useful tool to limit the spread of multi-drug resistant TB. This list does not require the integration of multiple databases nor does it involve secret intelligence transmissions from multiple overseas sources, as was the case with the Christmas day bomber. It must, however, be integrated into routine security screening. Its success relies on the awareness of actors at every level, from the state health officials who report potential "flight risk" patients to CDC to the airline and TSA agents who must notice and act on warning signals. The failure to protect the public from an easily avoidable health threat on January 9 suggests strongly that the list and the concerns behind it are not yet a regular part of airline security awareness and response.
In 2007, CDC believed the threat of a passenger flying internationally with (then suspected) extensively multi-drug resistant TB to be urgent enough to warrant potential violations of Mr. Speaker's legal rights to stop him. Congress and DHS agreed that the problem was severe enough to require a new system for addressing such threats systematically. Almost three years later, tools like the list have been developed but do not appear to have been forged into a consistently effective deterrent - at least, not one taken seriously by all actors.
In the wake of the Christmas Day bomber, authorities are reexamining security shortcomings on all levels. This is the perfect time to make sure that the warning system for contagious flyers is integrated into normal decision-making processes at airports and borders. While this may sound complicated, it is far less problematic than trying to create a fool-proof anti-terrorism strategy for airlines. CDC has already figured out how to filter "disease intelligence" up from the local doctor's office to Atlanta and Washington - now TSA and the airlines need to figure out how to act on it.
Photo courtesy of: http://www.flickr.com/photos/lrargerich/3303807650/
Vidal Seegobin is a Research Associate with the Global Health Security project at the Stimson Center.